In northern Italy, just two weeks ago, doctors found themselves inundated with patients sickened by the new coronavirus.
One large hospital had roughly 500 patients positive for COVID-19, the disease caused by the virus. As many as 90 new patients with COVID-19 symptoms arrived each day. The onrush of patients overwhelmed the hospital’s medical supplies, protective equipment for workers and, most importantly, ventilators needed to keep many COVID-19 patients alive. And the scene was the same at every hospital across the region.
“There is no way to find an exception,” one Italian doctor told the New England Journal of Medicine. “We have to decide who must die and whom we shall keep alive.”
If Colorado’s increasingly strict social distancing requirements fail, hospitals here could be facing this same situation in a matter of weeks. Health officials say there are 72 people with confirmed cases of COVID-19 currently hospitalized across the state, but hospitals report dozens more with suspected cases occupying specially designated wards and intensive-care units.
The possibility that Colorado hospitals could soon be overrun with more patients than they can treat has doctors now talking about doing something the state has never had to do before: activating the state’s crisis standards of care plan, which would help doctors decide whom to save when they can’t save everyone.
“It’s very military-style triage,” said Dr. Matthew Wynia, the director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus and a national expert on crisis standards of care.
“If we get hit that hard, we are going to have some very difficult decisions to make,” he said. “And we can’t wait until then to get ready for that. So at this point, our philosophy is that it would be irresponsible not to plan right now for a huge surge of patients.”
A framework for the unthinkable
Colorado’s official crisis standards of care plan was signed by then-Gov. John Hickenlooper in 2018 after years of work both locally and nationally. Dr. Stephen Cantrill, an emergency medicine specialist at Denver Health who helped write the standards, said the need to develop something to provide doctors both guidance and legal protection stemmed from the nation’s experience during Hurricane Katrina, when hospitals were left without electricity and doctors couldn’t save all their patients.
Colorado’s plan requires an executive order from the governor to implement. The state is not there yet, but may be “inching closer,” Cantrill said. Wynia said a small committee met Monday to talk about when that order might be needed.
“It’s something you just hate to do, but you want to do it in an organized fashion with fairness to all,” Cantrill said.
The state’s official plan is less a point-by-point instructional guide than it is a framework for how state officials, hospitals and doctors should implement crisis standards. For instance, it tells health care providers to make sure their crisis policies are driven by fairness, transparency with the community and a desire to deliver the greatest good to the greatest number of people.
It also provides guidance for when it is appropriate to shift to crisis standards of care — such as when there is a severe staffing shortage, overwhelmed capacity or “some or even many critical resources are unavailable, potentially including hospital beds, ventilators, and medications.”
After the executive order authorizing their use, Cantrill said the decision on when to shift to crisis standards of care must be made at the local level — when one community is overwhelmed, another might not be. But the plan also offers some examples of how hospitals could triage patients. And this is where the grim reality of what that might look like starts to set in.
Wynia said triage decisions are first made based on medical circumstances. One possible triage system included in an appendix to the plan, for instance, contemplates a points system for new patients. Those who are older, who have dangerously low blood-oxygen levels or who are having severe difficulty breathing score higher — meaning they are seen as being the less likely to survive and, thus, less likely to receive a scarce treatment when vying for that treatment against lower-scoring patients.
But Wynia said determining who is most likely to die even with treatment and who is most likely to be saved by it is the first step in potential triage systems. He pointed to examples from Maryland and New York, which looked at whether preference should be given to medical workers on the premise that, once healed, they can return to the front lines to save others.
There’s debate, Wynia said, about whether underlying medical conditions — like a cancer that could eventually prove fatal — should be factored in. It’s controversial how much age, on its own, should be considered, Wynia said.
Characteristics such as race and socio-economic status should not be considered, experts agree. Wynia said an ideal setup would have an independent triage team at a hospital making these decisions with only the necessary information about patients. The doctors actually treating the patients would not have a say.
But, if there’s no other way to decide, Wynia said it could come down to simple chance: A lottery.
“If you can’t make the decision based on clinically relevant factors, that’s what public polling and focus groups have told us people think is fair,” he said. “If push really comes to shove, that is the fairest way to allocate a very scarce resource.”
A hope it won’t be needed
Though they have spent years of their careers planning for how hospitals should handle such crises, Wynia and Cantrill both say they desperately hope their work won’t have to be put into practice. But Cantrill said it would be unwise to expect that help from the federal government or elsewhere arrives to spare the state from the worst.
“The way this goes, you can’t really wait for the cavalry,” he said. “They’re spread pretty thin.”
And Wynia said planning for the worst forces health leaders to get creative in order to avoid it. Could hospitals conserve ventilators by figuring out how to hook two patients up to a single one? What about four patients?
But both said just the thought of implementing crisis standards of care is stressful. There are too many consequences to consider; the reality is too awful. They hope Coloradans take the orders to stay home seriously.
Wynia said he’s not sleeping much.
“My whole life, I have never had much trouble falling asleep or staying asleep; it’s like a joke in my family that I can drop off anywhere,” he said. “But I have been doing a lot of tossing and turning. You lay down in bed and things start flowing through your mind.”